Discover and read the best of Twitter Threads about #MayoIDQ

Most recents (24)

Images of Infectious Diseases

46F with diabetes presents with orbital apex syndrome. Imaging and histopathology shown. What is your differential diagnosis? #MayoIDQ to follow @StephanieGrach @ZYetmar @omarabusaleh15 Image
2/ #MayoIDQ
46F with uncontrolled DM and recent DKA is admitted because of left sided HA for a month. PE: orbital apex syndrome. Head imaging shown. ENT/neurosurgery proceeded with debridement. Pathology shown. Which one of the following choices is most correct?
Case diagnosis: Rhinocerebral #mucormycosis due to #Rhizopus in a person with poorly controlled diabetes mellitus

Surgical debridement
Liposomal #Amphotericin B

Later: transitioned to #Posaconazole upon clinical control and improvement
Read 6 tweets
Images of Infectious Diseases

“Food gets stuck in my Adam’s apple”

A 68 year old man presents with weight loss and dysphagia for 6 weeks. Upper endoscopy is shown. What is your diagnosis? #MayoIDQ and case details to follow Image
68M. No PMH. 6w gradual dysphagia to solids with 20 lb weight loss. No F/C/sweats. PE: cachexia. WBC 4.7 Cr 0.9 CXR normal. HBV(-). Rx fluconazole.

Per your suggestion: HIV VL 56K CD4 26. Patient willing to start ART immediately. Genotype pending. You suggest which one?
Case diagnosis: Esophageal candidiasis in a man with newly diagnosed AIDS

Suggested ART: TAF-FTC-bictegravir

ART consists of 2 NRTI in combo with 3rd drug: INSTI, NNRTI or boosted PI.

Among them: INSTI is preferred for various reasons (next)
Read 6 tweets
Images of Infectious Diseases

2 months after visiting family and friends in Manila:

39M. No PMH. One week of fever, chills, cough, pleuritic chest pain, RUQ pain.

Now complains of blurred vision due to endophthalmitis.

Your DDx? #MayoIDQ and case details to follow… Image
39M. No PMH. HIV-. No IDU.
PE: jaundice, endophthalmitis, no dental issues, b/l rales, new systolic murmur, tender RUQ
WBC 18.3 Alk phos 250.
CT chest / abdomen (photo)
TEE: mitral valve vegetation
Which of the following is the most likely pathogen? #MayoIDQ
Let us use this case to highlight clinical pearls about liver abscess:

Two major categories
1. Pyogenic liver abscess
2. Amoebic liver abscess

In this case, there are factors that favor pyogenic liver abscess: endocarditis, septic pulmonary emboli and endophthalmitis
Read 9 tweets
Images of Infectious Diseases
58M. NYC. No PMH.

1 mo ago: high dose prednisone, rituximab, plasma exchange for presumed paraneoplastic autoimmune polyneuropathy.

Now: PET-CT. Biopsy (shown)

ROS: fever, cough, chest pain
What is the DDx? Case details #MayoIDQ to follow… Image
No travel. No farm exposure. No pets.
Work up:
CXR RML opacity
WBC 13.7. 94%N.
HIV neg.
Galactomannan negative
Histoplasma serology negative
BDG >500
What is the most likely pathogen? #MayoIDQ
Case diagnosis: #Pneumocystis jirovecii pneumonia presenting as solitary granulomatous inflammatory nodule

BAL PJP smear / PCR negative
Biopsy: PJP

Repeated PCR of stored BALF: low +
Read 6 tweets
Images of Infectious Diseases

A young man presents to the ER because of leg numbness. While undergoing evaluation, he had a seizure. CT head is shown (photo). #IDTwitter what is your differential diagnosis?

Case details #MayoIDQ MCQ to follow… Image
36M migrant from Mexico
No PMH. HIV negative.
CC: leg numbness
ED: witnessed seizure
WBC 16. Cr 0.7. AST 35.
CT (photo)

Which one of the following is least likely the correct answer about this condition? #MayoIDQ
Case diagnosis: #Neurocysticercosis NCC due to #Taenia #solium

There was an almost equal spread in the answers (probably due to poorly constructed MCQ :-) )

The least likely correct association is undercooked pork…. which leads to #taeniasis but not directly to NCC
Read 7 tweets
Images of Infectious Diseases

42M on obinutuzumab for CLL. 4 mo ago: mild COVID-19 - no specific Rx. 3 mo ago: SARS-CoV-2 mRNA vaccine.

CC: 2 mo on/off fever, cough, dyspnea. NP SARS-CoV-2 PCR neg. Rx as CAP w doxycycline - no response.

CT chest. DDx? Work up? #MayoIDQ next Image
Four months after mild COVID-19, an ICH man with CLL on obinutuzumab presents with prolonged / recurrent doxycycline-non responsive CAP. CT chest shown. See prior tweet for other details. Which of the following is the most likely diagnosis? #MayoIDQ
All of the MCQ choices could be possible in this case. Imaging suggested viral or PJP.

Work up:
Serum BDG / GM negative
CMV PCR negative
BAL PJP PCR negative
SARS-CoV-2 spike/nucleocapsid Ab negative (despite infection / vaccine)
Read 12 tweets
Images of Infectious Diseases

This is middle turbinate of a 64 ICH with epistaxis s/p CAR-T for refractory diffuse large B cell lymphoma.

What is your DDx? #MayoIDQ next Image
64M refractory DLBCL
s/p CAR-T —> cytokine release syndrome Rx tocilizumab and steroids

CC: epistaxis x 2w
PE: lesion in hard palate; nasal endoscopy (photo). CT dense material in sinuses.

What is next best step?
Biopsies from left hard palate and nasal cavity lesions were obtained (photo). Culture: Fusarium sp.

Suggested answer: ENT surgery for biopsy / diagnostics + debridement

Often: diagnostics and empiric Rx are concurrent in real life. Image
Read 4 tweets
Images of Infectious Diseases

H&E of brain biopsy specimen.

Who is the host? What is the most likely pathogen? How do you treat?
#MayoIDQ Image
2/ #MayoIDQ
75F. Immunocompetent.
CC: headache x few months —> now left leg weakness, blurred vision, seizure. CBC/CMP normal. CT head: mass in right ventricle, pons. CT chest/abdomen for CA work up (-). Brain biopsy (photo).

Which of the following is the most likely pathogen?
Case diagnosis: cerebral #phaeohyphomycosis due to #cladophialophora

Note pigmented hyphae —> excludes Aspergillus (hyaline septate mould)

Among 3 remaining choices, the most common neurotrophic dematiaceous mould is Cladophialophora bantiana
Read 7 tweets
45M CC: tender mass on left thigh that started as an “insect bite” 4 days ago. No F/C. PE: tender fluctuant 2-cm mass with surrounding erythema.

After I&D of abscess in the clinic, what do you recommend?
2014 IDSA guideline recommends incision and drainage of purulent SSTI (abscess)

Antibiotics vs MRSA / S. aureus as an adjunct to I&D if:
2. Failed initial Ab Rx
3. Impaired host defense

Any new data since then?…
After 2014 IDSA guideline, placebo-controlled RCTs were published on use of antibiotics (TMP SMX or clindamycin) for uncomplicated SSTI abscess ... (next)…
Read 5 tweets
#MayoIDQ: 86M DM

2 wk of R ear pain / nasal discharge

Now: R frontal HA, facial pain, vision loss

PE: R ptosis, CN III, IV, VI palsies, purulence R middle meatus

CT: R sided paranasal sinusitis w/ phlegmonous extension to orbital apex

What is DDx, work up and etiology?
Diagnosis: Orbital Apex Syndrome

S/S due to involvement of structures in orbital apex: most common vision loss and painful / limited eye movement

CN palsies
* Optic nerve
* Oculomotor nerve
* Trochlear nerve
* First division of trigeminal nerve
* Abducens nerve
DDx (overlapping symptoms) of orbital apex syndrome

1. Cavernous sinus thrombosis
2. Superior orbital fissure syndrome…
Read 7 tweets
Images of Infectious Diseases

28F SLE on MTX
CC chest pain, vaginal DC
Rx pred for lupus

2 mo: fatigue, pruritic rash, visual floaters Rx pred

1 mo: blurred vision. PE iritis / chorioretinitis. Rx pred

Now b/l vision loss. PE panuveitis + chorioretinitis

DDx? #MayoIDQ Image
28F HIV/HBV/HCV(-) SLE on MTX w chronic pain Rx as flare, vaginal discharge due to BV Rx metro (negative GC/chlamydia), skin rash x 2 w and progressive vision loss (photo). CXR clear. Indiana / no foreign travel. No animal exposures.

What is most likely diagnostic test?
Case diagnosis: bilateral ocular syphilis with neurosyphilis

RPR 1:512
Syphilis antibody with reflex: positive

Rx: IV penicillin
Read 8 tweets
#MayoIDQ 69M was brought to the ED because of weakness. PE: intoxicated disheveled man with multiple skin ulcers / excoriations.
WBC 27. CK 1486. AST 76.
Wound culture: Clostridium botulinum

Which of the following is most consistent with wound botulism?

#Botulinum neurotoxin binds to cholinergic nerve terminals and cleaves intracellular proteins needed for #acetylcholine release —> reduced acetylcholine —> neuromuscular blockade —> bulbar palsies, hypotonia, and symmetric, descending, #flaccid #paralysis.

Clinical features
1. Flaccid paralysis
2. Prominent cranial nerve palsies
3. Descending progression
4. Symmetrical presentation
5. No sensory nerve dysfunction.

43% are correct in MCQ…
Read 11 tweets
Weekend Digest

Name the pathogen!

H & E stain of heart tissue of a 27M who developed severe intractable heart failure 2 months after an allogeneic bone marrow transplant for acute leukemia.

Clue: consumption of food / water contaminated with feces of snakes
1. Sarcocystis hominis, suihominis, nesbetti, others
2. Zoonotic: 2 forms for human infection
3. Intestinal and muscular sarcosystosis
4. Dx: intestinal (O/P), muscular (biopsy)
5. Rx: not well defined; TMP-SMX, albendazole, others…
Intestinal #Sarcocystosis
1. Ingestion of sarcocyst (S. hominis / beef, suihominis / pork) in tissue
2. Sarcocyst digested —> bradyzoites —> intestinal infection / gametes —> oocysts / sporocyst detected in stool
3. Self limited. No Rx needed…
Read 5 tweets
Images of Infectious Diseases

GMS of sinus tissue of 20F with no PMH. She presented with fever and sinus pain. CT pansinusitis. Labs: WBC 1.7 ANC 0. Serum BDG and GM negative.

What is your differential diagnosis and empiric therapy? #MayoIDQ to follow... Image
Histopath of surgically resected tissue shows fungal elements. You suggested Mucor/Rhizopus, Fusarium, Trichosporon.

Lack of serum BDG suggests Mucor/Rhizopus

The patient was started on AmBisome.

Few days later, the fungal culture of the same sinus sample shows (photo) Image
#MayoIDQ Surgical debridement of the sinuses was performed plus liposomal Amphotericin B was initiated. Patient lives in rural MN and asks you if an oral option is available as step down Rx.
Read 9 tweets
Images of Infectious Diseases

6 mo post-tx: H&E (400x) of cervical biopsy of 46F s/p living unrelated donor kidney tx for adult PCKD.

Belatacept. MMF. Prednisone.
Acute cellular + antibody-mediated rejection.

CMV D+/R-. valganciclovir prophylaxis.

DDx / Rx? #MayoIDQ next Image
Case diagnosis: breakthrough CMV disease with cervicitis

H&E intranuclear / intracytoppasmic inclusions within endothelial cells in ectocervical stroma.

Immunohistochemistry stain for CMV shows infected endothelial cells with CMV inclusions.… Image
#MayoIDQ Breakthrough CMV disease, while receiving valGCV prophylaxis, is concerning for over-immunosuppression, under-dosing of val GCV, and/or drug-resistant virus.

If gene sequencing shows the most common CMV gene mutation, what drug would be recommended Rx?
Read 9 tweets
Images of Infectious Diseases

This is GMS stain and culture of a skin biopsy from a patient’s leg.

Who is the host? What is the syndrome? Name the pathogen. How to treat?
#MayoIDQ and case details to follow... Image
66M. 4 mo after heart Tx: painless leg nodules that spread distally x 5 weeks. No pain. No fever.

PE unremarkable except lesions in left leg / foot + tinea pedis

Biopsy: GMS fungal elements in dermis. Culture: Trichophyton rubrum

What is true of this condition?
Case diagnosis:
#Majocchi’s Granuloma due to #Trichophyton rubrum

Histopath shows fungal elements (GMS) - not sufficient for identification.

Important: Send specimen for culture identification!!!

Treatment: Itraconazole Rx
Read 9 tweets
A series of images presented by an ID fellow to a faculty panel in the “Challenging Cases” session of the #MayoIDFellowsForum

The fellow asked the experts: What diagnosis comes to mind?

#IDTwitter, what do you think?
Clinical details, #MayoIDQ and MCQ to follow...
Awesome list of potential pathogens... from staphylococcus / streptococcus to nocardia, TB, fungi (Mucor, Candida, endemics) and toxoplasma, and others.

Without knowing the host and scenario, all are possible. Thank you #IDTwitter.
Now let us learn about the case details..
45M found unconscious.
PMH: alcohol use disorder. No IDU.
PE: T103F RR32 PR110
Murmur. Rales.
No skin lesions.
WBC 27K.
Imaging (photo). No PFO.
CSF TNC 9450 /N92% /prot 150 / glu 20

Name the pathogen.
Read 16 tweets
70M with swollen R 5th digit, hand and forearm. No fever / chills.

MRI: complex multi-compartment fluid collection with extensive flexor and extensor tenosynovitis

Debridement. Culture (photo).

What is your diagnosis and Rx?
#MayoIDQ MCQ to follow... Image
Elderly man with swollen right hand and forearm. MRI: complex fluid collection, extensive tenosynovitis. Debridement performed. Culture is shown (photo prior tweet).

Which of the following is the exposure associated with this infection?
Beaver dam and blastomyces

When #IDBR says #beaverdam - you think #BLASTOMYCOSIS…
Read 9 tweets
Images of Infectious Diseases

This is the histopath and gram stain of culture of a lymph node biopsy of a person with tender purulent inguinal adenopathy.
Dr. @dwchallener
Dr. @ali_eberly
MCQ #MayoIDQ to follow Image
72M. Crohn’s. 2 pet dogs. 1 pet cat.
2 mo after L knee surgery —> tender L inguinal node with purulence. No F/C. No response to TMP-SMX.

Biopsy (see photo): Stellate suppurative granuloma with central necrosis and clumps of bacteria.

What is the most likely diagnosis?
#Gram stain: a first step in bacterial identification —> two major groups:
1. Gram-positive: retains primary stain (crystal violet)
2. Gram-negative: does not retain crystal violet but counterstained by safranin/fuchsine —> red / pink

Named after Hans Christian Gram (photo) Image
Read 12 tweets
On day 14 of neutropenia, an astute ID fellow noted this finding (photo) while examining a patient with fever. Underlying AML and ongoing chemotherapy.

What do you suspect? What work up do you suggest? Details and #MayoIDQ MCQ to follow...
65M acute myeloid leukemia. Rx: CLAG-M. Prophy ACV, posaconazole, Levo, inhaled pentamidine

D14 neutropenia: fever / chills
Exam: onychomycosis, rapidly evolving lesions in arms and torso (photo)

You asked for skin biopsy. Blood culture will grow what fungus?
Case diagnosis: disseminated fusariosis

Majority got the diagnosis correctly!
Blood culture: Fusarium sp.

Rx: AmBisome / voriconazole
Hope for neutrophil recovery!!!
Read 12 tweets
Images of Infectious Diseases

56M Mexico. Chronic abdominal pain, weight loss, anorexia.

Work up: elevated markers (CA19-9, CA-125, AFP). CXR normal. CT peritoneal carcinomatosis.

Laparoscopy (photo). Biopsy showed granuloma. What is your DDx? #MayoIDQ MCQ next... Image
Thank you for your responses.

Culture of tissue (peritoneal nodules) of this 56M (see prior tweet) with granuloma on biopsy: Mycobacterium tuberculosis complex. Resistant to pyrazinamide.

Which of these choices is the most likely mechanism of transmission?
Case diagnosis: Peritoneal #tuberculosis due to #Mycobacterium #bovis

Path: granuloma and positive #AFB stain
Culture: M tuberculosis complex

Clue: #PZA resistance —> THINK M. bovis

Reported by @GaboMotoa during his rotation in Mayo Clinic…
Read 11 tweets
Images of Infectious Diseases

This is the peripheral blood smear of a 71M s/p splenectomy. Rural Wisconsin. No travel.

CC: fever, sweats, dyspnea
ROS: dark urine
PE: jaundice
Hgb 10. Low haptoglobin.
TBI 3.3 LDH 1075

What is the diagnosis and recommended Rx?
#MayoIDQ MCQ next
71M. WI. (see prior tweet)
S/p splenectomy.
Fever, jaundice, hemolytic anemia.

Your diagnosis: babesiosis (parasitemia 7.3%).

3 days after starting Rx: tinnitus and hypoacusis

What Rx most likely caused this adverse effect?
Treatment of #Babesiosis
1. Atovaquone-azithromycin
2. Quinine-clindamycin

The two regimens have comparable efficacy in non-life-threatening babesiosis.

BUT safety profile of Atovaquone-azithromycin was better…
Read 10 tweets
There is no proven effective antiviral drug for the treatment of #SARSCoV2

Several compounds are suggested for Rx of #COVID19. Based on the available in vitro and clinical data, which one is your preferred Rx, if available? #MayoIDQ references follow...

Several potential mechanisms: change in cell membrane pH, impairs viral fusion, interferes with glycosylation of viral proteins

#chloroquine and #redemsivir are active against SARS-COV2 in experimental models…
- Analogue of chloroquine
- Anti inflammatory effect

Hydroxychloroquine was more potent than chloroquine against #SARS-CoV2 in vitro.…
Read 17 tweets
Images of Infectious Diseases

74M Iowa farmer s/p Dacron graft repair of abdominal aortic aneurysm

2y later: back pain
MRI (photo) + enhancement of graft + aneurysm

Surgery (photo): bacteria, fungi/TB cultures (-)

DIF with anti-Coxiella Ab in fibroblasts (photo).
(MCQ next) Image
In a 74M farmer with multilevel vertebral osteomyelitis and soft tissue abscess contiguous with vascular graft and mycotic aneurysm, which serological pattern is most consistent with a diagnosis of chronic Q fever? #MayoIDQ (PI phase 1; PII phase 2 titers)
Case diagnosis: Chronic #Coxiella burnetti infection (#QFever): vascular graft, vertebral osteomyelitis, soft tissue abscesses

MCQ answer: choice B

Description reported by @AbinashVirkMD, @DOCElie and colleagues…
Read 10 tweets

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